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Regenerative Medicine
Muse Stem Cells
IV Stem Cells
Joints Stem Cells
Weight Loss and Anti Aging
Aesthetic Medicine
Weight Loss/Peptides
Vitamin IV/Shots
Mens Health
EBOO
Other Services
Medical Tint Exemption
Labwork
Suboxone Therapy
About
Regenerative Medicine
Muse Stem Cells
IV Stem Cells
Joints Stem Cells
Weight Loss and Anti Aging
Aesthetic Medicine
Weight Loss/Peptides
Vitamin IV/Shots
Mens Health
EBOO
Other Services
Medical Tint Exemption
Labwork
Suboxone Therapy
About
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Medical Tint Exemption Intake
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Please enable JavaScript in your browser to complete this form.
Name
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Last
Phone
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Email
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Gender
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--- Select Choice ---
Male
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Date of Birth
*
What of registrant
What is Your Florida Drivers License Number or Florida ID card Number?
*
Registrant Address
*
Address Line 1
Address Line 2
City
--- Select state ---
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Is your shipping address the same as your registrant address
*
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Shipping Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
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Rhode Island
South Carolina
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Tennessee
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Vermont
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Wisconsin
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State
Zip Code
Do you agree to opt-in for text message notificaiton for: Updates from your healthcare provider, Shipping updates or Office staff notifications
*
Yes
No
Medical Tint Exemption
What are you trying to use a medical tint exemption to help with?
*
Lupus (with positive ANA titer)
Dermatomyositis (with positive ANA titer)
Albinism
Total or Facial Vitiligo
Xeroderma Pigmentosum
Other Autoimmune Diseases
Other medical condition which requires a limited exposure to light (ex.Photodermatitis/Cancers/Photophobia/Rosacea/Glaucoma etc.)
None of the above (Please note you will not be approved if selected)
How many vehicles are you looking to obtain an exemption for
*
1 -
$250.00
2 -
$350.00
3 -
$450.00
Please note if not approved full refund will be given
Vehicle 1-Title Number (It is on your vehicle's registration)
Vehicle 1-Vin Number
Vehicle 1-Year
Vehicle 1-Make
Vehicle 2-Title Number (It is on your vehicle's registration)
Vehicle 2-Vin Number
Vehicle 2-Year
Vehicle 2-Make
Vehicle 3-Title Number (It is on your vehicle's registration)
Vehicle 3-Vin Number
Vehicle 3-Year
Vehicle 3-Make
Upload a picture of FL drivers license or ID card
Drag & Drop Files,
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Total
$0.00
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